In the US, children from minority ethnic and racial backgrounds suffer disproportionately from asthma. Despite well established guidelines, under-treatment for asthma is common, especially for poor and minority populations. Our prior work has demonstrated that school-based directly observed therapy (DOT) of preventive asthma medications can improve outcomes for poor, urban children with persistent asthma. We have also found that school-based telemedicine can effectively facilitate assessments by primary care providers (PCPs) for preventive medication prescriptions for DOT and for follow-up care. However, to our concern we have found that children do not benefit equally from our programs. Specifically, among the subgroup of children with moderate to severe persistent or difficult to control asthma at baseline, the majority did not achieve control despite these school-based interventions. In fact, despite telemedicine follow-up assessments with PCP prompting for guideline-based step-ups in treatments, many of these children remained under-treated. We realize that our existing programs may be insufficient for these children, since they do not include specialist consultation for optimization of medication management or for identification and treatment of co-morbid conditions and triggers. Importantly, specialist care is substantially underutilized by poor and minority children who bear the greatest morbidity burden from asthma, leading to inconsistent delivery of guideline-based treatments and continued disparities. In response to PAR-15-279, we propose an innovative school-based program for urban children with moderate to severe persistent or difficult to control asthma. The Telemedicine Enhanced Asthma Management-Uniting Providers (TEAM-UP) program enhances our school-based, primary care directed asthma program with specialist-supported care to ensure optimal guideline-based treatment. We propose a randomized trial of TEAM-UP versus an enhanced care comparison group. We will prompt PCPs of all enrolled children (n=360, 4-12 years) to initiate school-based DOT of preventive asthma medication and will recommend referral to an asthma specialist. For children in TEAM-UP, the specialist visits will be facilitated via telemedicine at school. The initial telemedicine specialist visit will be scheduled after 4 weeks of DOT, in order to allow for accurate guideline-based assessments of medication and care needs once adherence with a daily controller medication is established. There will also be 2 telemedicine follow-up specialist visits to assess the child's response to treatment and make needed adjustments. We will capitalize on the existing community infrastructure by implementing both telemedicine and DOT in schools, and maintaining collaboration with the PCP. We will assess the clinical and cost-effectiveness of TEAM-UP in reducing morbidity and improving guideline-based care (primary outcome: symptom-free days at 3, 6, 9, and 12 months) versus enhanced care. At the study's completion, the program will be better defined as a sustainable means to improve care and reduce morbidity for high risk children with difficult to control asthma.